Marshall Gregory Solomon, DPM, FABPOPPM, FACFAS discusses the diagnosis and treatment of rheumatoid arthritis. Dr Solomon provides an in depth coverage to surgical options to reconstruct the rheumatoid foot.
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Marshall Solomon, DPM
Director of Podiatric Medical Education
Chairman, Department of Podiatric Medicine & Surgery
Farmington Hills, MI
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Male Speaker: The slide introduces me. I just want to say I want to thank the Residency Summit Committee for inviting me to lecture to you this morning. What we'll do is we'll try to get through this lecture quickly. There is a longer lecture which is on e-Learning Present that goes into greater detail on this. But we were going to focus on one part. We're gonna focus on forefoot reconstruction and and in rheumatoid arthritis, to make some medical and surgical considerations, what surgical options we have and I’m gonna really focus on the first ray correction instability in rheumatoid arthritis. I think what we have to do is start with a definition, I have no disclosures by the way, and here are the learning objectives, and then we'll start with the definition. Rheumatoid arthritis is a chronic systemic, non-supportive inflammatory disease characterized by symmetrical peripheral arthropathy with a predilection for the hands and the feet. The American Rheumatism Association has devised a criteria for diagnosis of rheumatoid arthritis, essentially there are seven basic diagnosis: morning stiffness that last more than an hour, arthritis that can occur a three or more joints, the hand involvement, systemic involvement, rheumatoid nodules, rheumatoid factors which we'll talk about another diagnostic lab test. It’s much more specific and then radiographic changes. The key is to have 4 out of 7 to meet the criteria and the first four, stiffness, through systemic arthritis must be present for at least six weeks. Now the test that we're using more commonly and you may be familiar with is the Anti-CCP. This is a peptide antibody which has high specificity when it's positive for rheumatoid arthritis occurring in 10 to 15 years. And depending on the level reported back, if it's high, it does of course, when it comes back positive, it confirms rheumatoid but it also gives you an indication of how destructive potentially it can be on joints. So the clinical presentation essentially is patients will percept with their pain, sort of a metatarsalgia, where they may have some burning discomfort around the sub metatarsal heads which maybe misdiagnosed as neuritis or neuroma. Eventually the developed subluxations, hammertoes, they have the development in drifting of the digits laterally, developed of bunions and eventually hallux the valgus bunion deformity. All characteristic with forefoot swelling which is not unusual in rheumatoid arthritic. Now the one thing that you need to make a differential diagnosis of is the difference between inflammatory versus mechanical disease and associated with morning stiffness. Rheumatoid arthritis or the inflammatory will be present and you'll have these signs. It's usually morning stiffness that's greater than an hour, there's significant fatigue, it generally improves with your activity, it worsens with rest, generally systemic in nature bilateral in response to steroids. Where mechanical is essentially the opposite. Now pathologically, the causes of inflammatory response in the joint affects the synovium. The synovial membrane thickens and it forms proliferative invasive granulation tissue called the pannus. This pannus continues to robe the soft tissues around the metatarsal phalangeal joint causing weakness of the capsule, the surrounding ligaments and eventually that pannus will cause erosion of the cartilage as well as erosion into the bone.
Radiographically what you’ll see is signs of subluxation, lateral drifting of the bone, and this is just the ongoing deterioration of the joint occurring by the pannus. Some of the early signs of x-ray findings you'll find are usually destruction subluxation, cystic changes and there's a couple of studies of Fletcher and Rowley that took 200 patients within six months of onset of the disease. 19% showed changes in their feet. Radiograph says compared to their hand radiographs and in one study by Simon that 26% of foot x-rays in diagnosing rheumatoid arthritis were positive in that there were no changes in the hand. What I generally take a look at and what is found, if you take a look at – to the slide to your right there is around the fifth metatarsal’s almost classic for early rheumatoid arthritis. There's localized swelling which leads to erosions of both medial and lateral aspects of the fifth metatarsal head. Eventually what happens is the inflammatory process in pannus causes, as I mentioned, erosion of the articular cartilage and their joint space narrowing that occurs along with subluxation. So let's focus a little bit about the goals of treatment. Well our primary goal in treating rheumatoid arthritic forefoot is to alleviate pain. To that end, we'll try to – we're trying to correct deformity or accommodate deformity and we’ll try to improve function and provide long term stability. This is the goals in treating rheumatoid foot. There are conservative management, non-surgical management, the use of extra depth shoes, shoe modifications, accommodative insoles, palliative care, and the judicious use of corticosteroid injections can be very beneficial in non-surgical approach and of course, physical therapy. Some pre-operative considerations I think one of those are age because when you’re dealing with a young rheumatoid versus an older rheumatoid, those procedures could be different in stabilizing them taking consideration of their activity, lifestyle, their activity. The disease progression it’s important to realize that rheumatoid arthritis is an ongoing disease. We can try to get the disease in remission but many times there will be exacerbations of RA. Rheumatoid arthritics don't just have rheumatoid arthritis. They can have associated systemic diseases. Those need to considered also. There's going to be vascular involvement, vasculitis, cardiac or pulmonary associated disease and rheumatoid arthritis. Again what we're gonna consider is maintaining good foot function or the ability of having them ambulate. We have to make sure that we have good skin integrity before we decide to operate on them because many patients that have advanced hammertoe deformities and subluxations develop abnormal pressures and they can develop skin ulcers. Vascular status speaks for itself which is certainly we don’t want to be operating on patients that will have a tendency not to heal. The biggest concern of course is vasculitis and you need to be aware of that. And then a very important thing is rheumatoid arthritics are being diagnosed early. Thank goodness. And as a result they’re being placed in disease modifying drugs which can reduce the amount of deformity and joint destruction that occurs in the disease but you need to be knowledgeable about that.
And then other systemic involvement in RA as we had mentioned earlier. Now to touch on this, I am certainly not a rheumatologist but I do deal with a lot of rheumatologist because I do a lot of rheumatoid surgery. And as a result knowing the medications that they're on is critical to timing of your surgical procedures. So one of the most common ones of course is methotrexate. It's an early medication that they use for treatment of rheumatoid arthritis. Some of these other medications that had been used in the past that are very good and the newer medications are the TNF inhibitors which you see advertised all the time. A majority of the patients are currently that have active rheumatoid arthritis are on. The key to these slide essentially is to understand that when the patient is on Enbrel, Humira or Remicade there is timing issues about when to do your surgery. You certainly don’t wanna be, such as Remicade, you wanna be on mid-cycle when you’re doing the surgery. If you have patients on methotrexate, you consult with a rheumatologist, thinking about discontinuing the Remicade between two weeks before. You gotta understand once they're off their rheumatoid drugs, they get very uncomfortable. So you need to understand what you can use to supplement their pain level when it comes to surgery. The other drugs you need to be familiar with of course is corticosteroids, most rheumatoids somewhere along the line have been on corticosteroids prednizone for their treatment of their rheumatoid arthritis. And certainly understanding that corticosteroids can suppress the hypothalamic pituitary adrenal access and when that suppressed, you put your patients at cardiovascular risk and vascular collapse. So you have to stress produce more steroids, so you always prep your patients if it's an outpatient procedure, start them with an extra-oral dose in the evening. Give them 100 milligrams of corticosteroid in the morning and then maintain them depending on the length of your procedure. There may be another dosing during the day and then gradually giving back to their normal dosing level. The other is a non-steroidal anti-inflammatories. The Cox 1, Cox 2, you need to be familiar with this. Cox 1s do inhibit platelet and alter bleeding time so this is important they need to be off of their medication for a minimum of seven days prior to it. The question of Cox 2 medication allowing that to go on board depending on your procedures. Generally, my feeling is to stop the medication prior to and then on Cox 2 so you can start them up following the procedure. So let's talk about the resectional arthroplasties. Well the mainstay really is been the Hoffman procedure for lesser metatarsal head resections or more severe cases the Clayton which is the resection of the bases of the proximal phalanx. Digital procedures and arthroplastic procedures to the first MP joint. This has been classic. It goes all the way back to Hoffman in his original published paper in 1912 and essentially he stated that this type of procedure for the patient that has rheumatoid arthritis, they feel much better by having their metatarsal heads removed. That's how painful it is. That procedure in itself has eliminated in the rheumatoid arthritic, a tremendous amount of discomfort. But taking into consideration of removing the metatarsal heads it’s just not the heads alone. You have to address the digits along with it and stabilizing the first ray in the first MP joint. There are several incisional approaches that are performed in the literature. The one that I prefer that approach is if you’re doing it through a dorsal approach is the Larman. It’s a three dorsal incision. One over the first metatarsal phalangeal joint and then one between the second and third metatarsals in the interspace and one in between the fourth and fifth.
This maintains a long soft tissue neurovascular island between the incisions. If you have large rheumatoid nodules plantarlly or dorsal, you may wanna consider a transfer sulcus incision plantarlly. To address that, you get the metatarsal heads out and the soft tissue but then it results in having to going back dorsally to stabilize the digits. Lesser digital procedures are essentially basically arthroplastic. Fusions of any type along with – if the bases are removed from the proximal phalanxes considers syndactilism. So let's talk about surgical considerations to the first ray. I think basically we are down to soft tissue procedures in the mild cases; arthroplastic procedures, arthrodesis osteotonomies, and plantar arthroplasties. So let's talk about the classics. The classics are Kellar arthroplasty, it's the most common. You can use a Kellar, modified Kellar with soft tissue modification, a Mayo procedure which is essentially modification of the head of the first metatarsal or combining the Kellar with the Mayo. Now essentially, there's a good relief for the Kellar. It is a time-tested procedure but in rheumatoid arthritis, it really isn’t the best procedure to standalone for pain associated with the deformity of the HAV. Initially, there's satisfaction but about 4 to 5 years down the road, 40-60% report dissatisfaction. The reason for that is essentially it's an unstable procedure. The retrograde force of the ground against the hallux dorsiflexes it, there's no stability, usually get joint space narrowing over a period of time with it and as a result there is increase lateral transfer pain into the lesser metatarsal areas. In a study that was performed by Pitzeles and Adele reported 56% dissatisfaction rate. 60% of the cases had instability and 80% over that period of time of 4 to 5 years had decreased joint space range at the first MP joint. So another consideration is first MP joint arthrodesis and essentially the indications for that include degenerative joint disease, inflammatory disease, post-traumatic arthritis, severe deformity in the joint and chronic instability. That probably is the criteria for anytime you would consider doing arthrodesis to the first MP joint. Counter-indications are obvious, vascularity, neuropathy, and disease of the IP joint. The big question is what position should I fuse that first digit? And I think you'll look through the literature and you will see that sagittal and transverse plane positioning is critical. How you do your arthrodesis is personal choice, you can do – and then like a [HASP] [19:09] procedure or you could use conical reamers which provide a little bit more stability in bone to bone interaction and this will be talked in greater detail by our next lecturer. And the key thing to keep in mind is if you have a pronated foot or a supinated foot, the fusion position is critical to ultimate function of that first ray and comfort for the patient. So generally metatarsal inclinationing should be equal to the arthrodesis angle for proper positioning in the sagittal plane. Essentially if you look at it, before you used to put a finger underneath the hallux and we thought that was like right for females.
And we used our little finger underneath the hallux for males. But essentially it really is a matter of understanding what's happening more proximally as I discussed. Fixation can occur through if cross K-wires, screws, screws of bone grafts, plates, plates with inter-positional bone grafts, these are very, very common. The reason for arthrodesis is that it does provide more stability. And in fact it does provide stability to the whole forefoot and by accomplishing that studies by Mann and Shackle, I have noted that – because you have a longer lever created by the fusion there is 41% less lateral transfer to the lesser metatarsals with the fusion. And there is less time that the foot is actually on the ground because you’ve created a longer lever. There are studies in arthrodesis also noted a high satisfaction rate of almost 90% following the procedure long term. The other is the use of locking plates. We are all familiar with this concept of locking plates and as a result, this is ideal in those conditions that have osteroporotic bone. I mean we can be faced with using some K-wires, that's always a back-up but sometimes we like a little bit more possible compression and stability of the osteotomy and ultimate fusion site. The use of compression screws, locking screws and non-locking screws hybrids, can be used to stabilize the first metatarsal. What's interesting about using locking screws at the fusion site, it does allow some micro-motion to occur that micro-motion creates more bone callus which helps in the ultimate fusion of the MP joint. Again the biomechanics behind it, it does create a fixed-angle coupling resulting in a better construct but a more catastrophic failure if it goes. If it fails, then the whole plates and screws come out as opposed to using a cortical screw or hybrid combination. And we talked about the concept of micromotion. Now if you are faced in and you tried to put on your plate and it doesn't work, you always go back to those good 0.062 K-wires that we learned how to use in our skills lab. Steinmann pin destabilize that. It’s excellent when we're using poor bone stock. Some alternatives to fusion of course are resection that we spoke to before and the implant arthroplasty. First, the ones that we'll discuss briefly are silastic total implant, the metallic hemi-implant and total metallic implant. The hemis have been a long stay, that's been used for a long time. We've had good success because it allowed for minimal resection of bone. It stabilized the MP joint and gave us a good range of motion and there was a high satisfaction rate. But it was technique-dependent and we saw that people wanted to take a little less bone and shove the silastic implant into the joint causing compression. Eventually, it developed sign of disthritis of the joint and we were getting silicone shards throughout the metatarsal and proximal phalanx. Then it was developed with [Gram] [24:36] which helped reduced that and I think that was beneficial that helped reduced some of the fragmentation and fracturing of the implant. And today that is more of the standard of using silastic total implants. Total metallic implants. First of all the two components once are very difficult to use.
They’re not forgiving if there is – they will fail if you don’t address proximal deformities such as elevatus or transverse plane deformities high IM angles. They just, the force at the MP joint with the metal implant does cause significant problems. And the does cause some bone interaction at the interface. The metallic hemi-implants essentially are a simpler procedure. Here, you can address a bad metatarsal head with a hemi, reconstruct that metatarsal head, do subchondral joint to create some fibrous changes over the head. And this base hem-implant will function very well. This procedure also allows you to address elevatus proximally if there is a descent bone-stock or transverse plane deformity. And I think we are familiar with this type of procedure. The key here is making sure that there is enough bone removed from the proximal phalanx so you don't create jamming. And the other caveat is to make sure that the sesamoidal apparatus is it generally over a long period of hallux reduction range of motion. There is fibrosis in adhesion of sesamoids underneath the metatarsal head and that should be freed via technique of choice. I used a McGlamry elevator for that. I think you should be aware of metatarsal osteotomies. This is really dependent on bone-stock but if you have proximal deformities you should address that especially in trying to stabilize the first metatarsal other than essentially fusion unless there is a high IM angle. While osteotomy increases the joint space if the articular cartilage is still descent. Post-operative care essentially dressings are essentially bulky but not restrictive recompression or compressive splints posterior splint right after allow for some post-operative swelling eventually back into a surgical shoe. The question is when to remove the hardware a little bit longer with rheumatoids because they’re immunosuppressed therefore it takes a little bit longer for osteotomy healing. K-Wires generally will come out where you would remove them at 4-6, might be 6-8. Hardware if they’re asymptomatic is left alone otherwise at least wait 4 months to 6 months before hardware is removed. The other consideration is how they are gonna get around, I think you need to take a look at their hand function , upper body strength, they may not do well with crutches or walkers so considerations of possibly a wheelchair or a roll-about maybe beneficial to them. Rehabilitation, physical therapy, getting them into post-operative care, orthotic in-lays are generally accommodative, metatarsal rises important sometimes in the accommodative orthotic shoe modification. Thank you.